Daniel C. Cherkin

Physician office visits for low back pain: Frequency, clinical evaluation, and treatment patterns from a u.s. national survey

Study Design. This study is an analysis of national survey data from 5 sample years. Objectives. The authors characterized the frequency of office visits for low back pain, the content of ambulatory care, and how these vary by physician specialty. Summary of Background Data. Few recent data are available regarding ambulatory care for low back pain or how case mix and patient management vary by physician specialty. Methods. Data from the National Ambulatory Medical Care Survey were grouped into three time periods (1980–81, 1985, 1989–90). Frequency of visits for low back pain, referral status, tests, and treatments were tabulated by physician speciatly. Results. There were almost 15 million office visity for “mechanical” low back pain in 1990, ranking this problem fifth as a reason for all physician visits. Low back pain accounted for 2.8 percent of office visity in all three time periods. Nonspecific diagnostic lables were most common, and 56 percent of visits were to primary care physicians. Specialty variations were observed in caseload, diagnostic mix, and management. Conclusion. Back pain remains a major reason for all physician office visity. This study describes visit, referral, and management patterns among specialties providing the most care.

A Comparison of Physical Therapy, Chiropractic Manipulation, and Provision of an Educational Booklet for the Treatment of Patients with Low Back Pain

BACKGROUND AND METHODS There are few data on the relative effectiveness and costs of treatments for low back pain. We randomly assigned 321 adults with low back pain that persisted for seven days after a primary care visit to the McKenzie method of physical therapy, chiropractic manipulation, or a minimal intervention (provision of an educational booklet). Patients with sciatica were excluded. Physical therapy or chiropractic manipulation was provided for one month (the number of visits was determined by the practitioner but was limited to a maximum of nine); patients were followed for a total of two years. The bothersomeness of symptoms was measured on an 11-point scale, and the level of dysfunction was measured on the 24-point Roland Disability Scale. RESULTS After adjustment for base-line differences, the chiropractic group had less severe symptoms than the booklet group at four weeks (P=0.02), and there was a trend toward less severe symptoms in the physical therapy group (P=0.06). However, these differences were small and not significant after transformations of the data to adjust for their non-normal distribution. Differences in the extent of dysfunction among the groups were small and approached significance only at one year, with greater dysfunction in the booklet group than in the other two groups (P=0.05). For all outcomes, there were no significant differences between the physical-therapy and chiropractic groups and no significant differences among the groups in the numbers of days of reduced activity or missed work or in recurrences of back pain. About 75 percent of the subjects in the therapy groups rated their care as very good or excellent, as compared with about 30 percent of the subjects in the booklet group (P<0.001). Over a two-year period, the mean costs of care were

Physician Views About Treating Low Back Pain: The Results of a National Survey

437 for the physical-therapy group,

Morbidity and mortality in association with operations on the lumbar spine. The influence of age, diagnosis, and procedure.

429 for the chiropractic group, and

A Review of the Evidence for the Effectiveness, Safety, and Cost of Acupuncture, Massage Therapy, and Spinal Manipulation for Back Pain

153 for the booklet group. CONCLUSIONS For patients with low back pain, the McKenzie method of physical therapy and chiropractic manipulation had similar effects and costs, and patients receiving these treatments had only marginally better outcomes than those receiving the minimal intervention of an educational booklet. Whether the limited benefits of these treatments are worth the additional costs is open to question.

Lumbar spinal fusion: A cohort study of complications, reoperations, and resource use in the medicare population

Study Design. Physicians were surveyed regarding their beliefs about treatment efficacy for patients with low back pain. Objective. To document physician beliefs about the efficacy of specific treatmets and the extent to which these beliefs correspond to current knowledge. Summary of Background Data. Little is known about physician beliefs regarding the efficacy of specific back pain treatments. Methods. A national random sample of 2897 physicians were mailed questionnaires that asked about 1) the treatments they would order for hypothetical patients with low back pain and 2) the treatments they believed were effective for back pain. Responses were compared with guidelines suggested by the Quebec Task Force on Spinal Disorders. Results. Almost 1200 physicians responded. More than 80% of these physicians believed physical therapy is effective, but this consensus was lacking for other treatments. Fewer than half of the physicians believed that spinal manipulation is effective for acture or chronic back pain or that epidural steroid injections, traction, and corsets are effective for acute or chronic back painor that epidural steroid injections, traction, and corsets are effective for acute back pain. Bed rest and narcotic analgesics were recommended by substantial minorties of physicians for patients with chronic pain. The Quebec Task Force found little scientific support for the effectiveness of most of the treatments found to be in common use. Conclusions. The lack of consensus among physicians could be attributable to the absence of clear evidencebsed clinical guidelines, ignorance or rejection of existing scientific evidence, excessive commitment to a particular mode of therapy, or a tendency to discount the efficacy of competing treatments.

Lessons from a trial of acupuncture and massage for low back pain: Patient expectations and treatment effects

We examined the rates of postoperative complications and mortality, as recorded in a hospital discharge registry for the State of Washington for the years 1986 through 1988, for patients who had had an operation on the lumbar spine. When patients who had had a malignant lesion, infection, or fracture are excluded, there were 18,122 hospitalizations for procedures on the lumbar spine, 84 per cent of which involved a herniated disc or spinal stenosis. The rates of morbidity and mortality during hospitalization, as well as the hospital charges, increased with the ages of the patients. The rate of complications was 18 per cent for patients who were seventy-five years or older. Nearly 7 per cent of patients who were seventy-five years old or more were discharged to nursing homes. Complications were most frequent among patients who had spinal stenosis, but multivariate analysis suggested that the complications associated with procedures for this condition were primarily related to the patients age and the type of procedure. Complications, length of hospitalization, and charges were higher for patients who had had a spinal arthrodesis than for those who had not. Over-all, operations for conditions other than a herniated disc were associated with more complications and greater use of resources, particularly when arthrodesis was performed, than were operations for removal of a herniated disc. No data on symptoms or functional results were available.

Back pain in primary care. Outcomes at 1 year.

Back pain and its sequelae place an enormous burden on society, health care systems, and the economies of developed countries (1). More than 50% of Americans experience back pain each year; most have pain for more than 1 week (2). In the United States,

A Randomized Trial Comparing Acupuncture, Simulated Acupuncture, and Usual Care for Chronic Low Back Pain

25 billion is spent annually on medical care services for back problems and another

Low back pain hospitalization: Recent united states trends and regional variations

50 billion is spent on lost productivity and disability payments (3). Despite the high prevalence of back pain and the numerous conventional medical treatments used for this problem, few treatments are supported by strong scientific evidence (4, 5). The limited effectiveness of conventional treatments has contributed to a high level of patient dissatisfaction with medical care for back pain (6). Thus, it is not surprising that back and neck problems are the main reasons why complementary and alternative medical (CAM) therapies are used and CAM providers are consulted (7, 8). Spinal manipulation, performed mostly by chiropractors in the United States (9), is the most popular CAM therapy for back pain in this country (7). Chiropractic has been licensed in all 50 states since 1974 (10) and is covered by most insurance plans (11). Massage therapy has become increasingly popular over the past decade and is currently licensed, or otherwise regulated, in 30 states (12). In 1997, 11% of Americans used massage, making 114 million visits to massage therapists (7). Although less common than chiropractic and massage, acupuncture, which is licensed in 39 states, is the third most frequently used CAM therapy for back pain in the United States. A recent study found that back pain is the most common reason for visiting chiropractors (40% of visits), massage therapists (20% of visits), and acupuncturists (about 14% of visits) (8). Few studies have evaluated the many other CAM therapies used for back pain; these include mindbody therapies (such as yoga, meditation, and tai chi), physical treatments (such as magnets, spa therapy, the Feldenkrais method, the Alexander technique, and Pilates-based exercises), botanicals (such as willow bark and Devils claw), and supplements (such as glucosamine sulfate and chondroitin sulfate). Over the past quarter century, numerous randomized, controlled trials (RCTs) have evaluated CAM therapies for back pain; in the past decade, reviews and meta-analyses of these trials have proliferated. The poor quality, inconsistent conclusions, and biases of many studies and reviews have led to confusion. We attempt to provide clinicians, patients, and health plans with a clear and balanced understanding of the current evidence about the effectiveness, safety, and cost of the CAM therapies most often used by Americans to treat low back pain: acupuncture, massage therapy, and spinal manipulation. Methods Data Sources We identified systematic reviews of RCTs that evaluated acupuncture, massage therapy, and spinal manipulation for nonspecific back pain published since 1995. In addition, we identified original articles that described results of RCTs published since the reviews were conducted. In accordance with the Cochrane Collaboration Back Review Groups guidelines for systematic reviews for spinal disorders (13), both the reviews and the subsequent original articles were identified by using a computerized search of MEDLINE (from 1966 to April 2002), EMBASE (from 1988 to 1 September 2001), and the Cochrane Controlled Trials Register (through September 2001). We used the specific therapies (acupuncture, massage, or manipulation) and back pain, low back pain, and backache as search terms. We also retrieved reference lists from recent original publications to identify additional trials. We searched MEDLINE for articles on the safety of acupuncture, massage, and lumbar manipulation. Because observational data on the relative costs of CAM and conventional care are subject to substantial bias as a result of the noncomparability of patients seeking care from CAM and conventional providers (14, 15), we extracted cost data only from the few effectiveness RCTs that measured cost. Two authors independently extracted descriptive data characterizing the reviews and original articles. Discrepancies were resolved after we jointly reviewed the original documents. Role of the Funding Sources The funding sources had no role in the design, conduct, or reporting of the study or in the decision to submit the manuscript for publication. Results Acupuncture Effectiveness In 1997, a nonadvocate, multidisciplinary panel was convened by the National Institutes of Health to evaluate the effectiveness of acupuncture. The panel concluded that, although basic research has begun to elucidate the mechanisms of action of acupuncture and promising results have emerged from clinical studies of acupuncture for emesis and postoperative dental pain, the value of acupuncture for other conditions (including back pain) was inconclusive and worthy of further study (16). Since this report, one meta-analysis (17) and two best-evidence syntheses (19, 20) have evaluated acupuncture for back pain (Table 1). A total of 14 RCTs were identified in these reviews; 11 were included in all 3. Most trials focused on nonspecific chronic back pain. The trials had serious limitations, including small sample sizes, inadequate acupuncture treatment, and high dropout rates. Table 1. Recent Systematic Reviews of Randomized, Controlled Trials Evaluating the Effectiveness of Acupuncture, Massage, or Spinal Manipulation for Back Pain Ernst and White [17], who considered 9 trials suitable for a meta-analysis, concluded that 1) acupuncture was superior to various control interventions and 2) evidence was insufficient to determine whether acupuncture was superior to placebo. Ernst and White asserted that their conclusions were based largely on rigorous research; however, the other reviews (19, 20), which used different quality rating scales, rated the studies less favorably and believed that meta-analysis would be inappropriate because the trials were heterogeneous in terms of design, type and duration of back pain, acupuncture treatment protocols, and outcome measures. Furthermore, van Tulder and colleagues (19) noted that most of the studies did not meet the current standards for conducting and reporting of RCTs. They concluded that the review did not clearly indicate that acupuncture is effective in the management of back pain and that high-quality RCTs were needed. Smith and colleagues (20) also concluded that more high-quality primary trials would be needed before clinically meaningful conclusions could be reached. Since the publication of these 3 reviews, we identified 6 additional published RCTs (Table 2) (27-32). In the largest trial, 262 patients with low back pain that had persisted for at least 6 weeks after a physician visit were randomly assigned to receive individualized Traditional Chinese Medical acupuncture, therapeutic massage, or self-care educational materials (30). Most patients had pain persisting for more than 1 year. Both treatment protocols proscribed use of herbs and oriental massage. After an average of 8 treatments over a 10-week period, acupuncture was found to be less effective than massage but equal to self-care educational materials in decreasing pain and improving function. Because there was no untreated comparison group, this study could not determine whether acupuncture was ineffective or merely less effective than massage. Table 2. Recent Randomized, Controlled Trials Evaluating Acupuncture, Massage, or Spinal Manipulation for Back Pain Published Too Late To Be Included in Systematic Reviews Summarized in Table 1 An Australian study randomly assigned 130 patients with chronic spinal pain (82% had low back pain) to receive acupuncture, chiropractic spinal manipulation, or nonsteroidal anti-inflammatory medication (27). Among the 77 patients who completed the study, neither back dysfunction nor pain significantly improved by the end of the 4-week treatment period in the acupuncture group. A Scottish study randomly assigned 60 elderly patients with chronic back pain to receive 4 weeks (2 sessions/week) of treatment with transcutaneous electrical nerve stimulation (TENS) or acupuncture (28). Acupuncture and TENS had similar effects on the severity of pain and use of analgesic medication. The acupuncture group, but not the TENS group, had a small but statistically significant short-term improvement in spinal flexion. Because a Cochrane Review has concluded that there is no evidence for the efficacy of TENS, it remains unclear whether either treatment was more effective than placebo (35). A Swedish study randomly assigned 50 patients with chronic lumbar pain to 8 weekly treatments of acupuncture or a placebo control in which a disconnected TENS unit was used (29). At the 1-month and 6-month follow-up evaluations, patients receiving acupuncture were significantly more likely to improve than were those receiving placebo. A Norwegian study randomly assigned 60 patients with acute low back pain to receive standardized acupuncture treatment for 2 weeks or enterosoluble naproxen at 500 mg twice daily for 10 days (31). Patients receiving acupuncture used substantially less analgesic medication after the first week of treatment and had fewer recurrences of low back pain after 6 and 18 months. However, pain relief between the groups did not differ. Finally, a German study randomly assigned 131 consecutive outpatients of an orthopedic department who had chronic low back pain to receive 12 weeks of active physical therapy alone (the control treatment) or in conjunction with real acupuncture or sham acupuncture (32). Real acupuncture was found to be superior to the control treatment but not to sham acupuncture in reducing pain intensity and disability. Safety Although tens of millions of acupuncture needles are used annually in the United States (36), only about 50 cases of complications resulting from acupuncture have be